Robin Berzin used to work with me at Health 2.0 , as well as combining her medical training with lots of media production and other work. Fast forward a decade and Robin has left the rest of us in the dust. She’s now the Founder and CEO of Parsley Health, which is a really innovative primary care++ clinic that is based on the foundations of functional medicine, and is having tremendous success treating and transforming the lives of thousands of patients who were not getting what they needed from the traditional health care syste,. Now Parsley is aggressively moving into the employer market. I caught up with Robin at the recent HLTH conference.–Matthew Holt
Above the Fold
Rube Goldberg Would Be Proud
By KIM BELLARD
Larry Levitt and Drew Altman have an op-ed in JAMA Network with the can’t-argue-with-that title Complexity in the US Health Care System Is the Enemy of Access and Affordability. It draws on a June 2023 Kaiser Family Foundation survey about consumer experiences with their health insurance. Long stories short: although – surprisingly – over 80% of insured adults rate their health insurance as “good” or “excellent,” most admit they have difficulty both understanding and using it. And the people in fair or poor health, who presumably use health care more, have more problems.
Health insurance is the target in this case, and it is a fair target, but I’d argue that you could pick almost any part of the healthcare system with similar results. Our healthcare system is perfect example of a Rube Goldberg machine, which Merriam Webster defines as “accomplishing by complex means what seemingly could be done simply.”
Boy howdy.
Health insurance is many people’s favorite villain, one that many would like to do without (especially doctors), but let’s not stop there. Healthcare is full of third parties/intermediaries/middlemen, which have led to the Rube Goldberg structure.
CMS doesn’t pay any Medicare claims itself; it hires third parties – Medicare Administrative Contactors (formerly known as intermediaries and carriers). So do employers who are self-insured (which is the vast majority of private health insurance), hiring third party administrators (who may sometimes also be health insurers) to do network management, claims payment, eligibility and billing, and other tasks.
Even insurers or third party administrators may subcontract to other third parties for things like provider credentialing, utilization review, or care management (in its many forms). Take, for example, the universally reviled PBMs (pharmacy benefit managers), who have carved out a big niche providing services between payors, pharmacies, and drug companies while raising increasing questions about their actual value.
Physician practices have long outsourced billing services. Hospitals and doctors didn’t develop their own electronic medical records; they contracted with companies like Epic or Cerner. Health care entities had trouble sharing data, so along came H.I.E.s – health information exchanges – to help move some of that data (and HIEs are now transitioning to QHINs – Qualified Health Information Networks, due to TEFCA).
And now we’re seeing a veritable Cambrian explosion of digital health companies, each thinking it can take some part of the health care system, put it online, and perhaps make some part of the healthcare experience a little less bad. Or, viewed from another perspective, add even more complexity to the Rube Goldberg machine.
On a recent THCB Gang podcast, we discussed HIEs. I agreed that HIEs had been developed for a good reason, and had done good work, but in this supposed era of interoperability they should be trying to put themselves out of business.
HIEs identified a pain point and found a way to make it a little less painful. Not to fix it, just to make it less bad. The healthcare system is replete with intermediaries that have workarounds which allow our healthcare system to lumber along. But once in place, they stay in place. Healthcare doesn’t do sunsetting well.
Unlike a true Rube Goldberg machine, though, there is no real design for our healthcare system. It’s more like evolution, where there are no style points, no efficiency goals, just credit for survival. Sure, sometimes you get a cat through evolution, but other times you get a naked mole rat or a hagfish. Healthcare has a lot more hagfish than cats.
I’m impressed with the creativity of many of these workarounds, but I’m awfully tired of needing them. I’m awfully tired of accepting that complexity is inherent in our healthcare system.
Continue reading…Some Like It Hot! A Century-Old Disease on Our Southern Shores
By MIKE MAGEE
Naomi Orestes PhD, Professor of the History of Science at Harvard, didn’t mince words as she placed our predicament in context when she said, “If you know your Greek tragedies you know power, hubris, and tragedy go hand in hand. If we don’t address the harmful aspects of human activities, most obviously disruptive climate change, we are headed for tragedy.”
At the time, as a member of the Anthropocene Workgroup, she and a group of international climate scientists were focused on defining and measuring nine “planetary boundaries,” environmental indicators of planetary health. At the top of the list was Climate Change because, one way or another, it negatively impacts the other eight measures.
Not the least of these “human perturbations” is the effect of global warming on access to clean, safe water, and the impact of violent weather cycles and rising sea levels on concentrated urban populations along coastal waters.
A less recognized, but historically well documented threat, is exposure to migrating vectors of disease as they contact unprepared human populations beyond their traditional camping grounds. The threat of avian flu among migratory birds has been well covered. Equally, over the past decade, North America has seen a range of novel infections, especially along our southern borders, from dengue, to chikungunya, to Zika.
The southern United States and its coastal populations are firmly in the cross-hairs. Their seas are rising at an alarming rate, and fouling fresh water supply with invasive sea water. Their soaring temperatures are only exceeded by record setting atmospheric river rainfalls and flooding events, and their “extreme poverty throughout Texas and the Gulf Coast states, where inadequate or low-quality housing, absent or broken window screens, and a pervasive dumping of tires in poor neighborhoods,” as reported in this weeks New England Journal of Medicine, assures a reemergence of one of this countries most significant, but now long forgotten killer diseases.
In 1853, the disease killed 11,000 in New Orleans, some 10% of the population. Twenty-five years later, it overwhelmed Mississippi Valley cities killing 20,000. Its latest major foray in the United States was in 1905 with 1000 deaths. Its’ absence over the past century is credited to public health and structural and engineering advances. But that was then, and this is now.
The disease is Yellow Fever, and red lights are blinking in a range of southern coastal cities from Galveston, TX, to Mobile, AL, to New Orleans, LA and Tampa, FL.. Experts say they may soon be in the same boat as Brazil was between 2016 and 2019 when it experienced a threefold increase in the historic prevalence of the disease among its population.
Public Health sleuths have uncovered that the 1878 epidemic in the Mississippi Valley was triggered by an El Nino spike the year prior. The warmer and wetter conditions are believed to have supported a large increase in Aedis aegypti mosquitos, the vector for the Yellow Fever virus.
Are we prepared? Recent experience in fighting Dengue fever in the southern statesis not encouraging, with WHO chief scientist Jeremy Farrar warning that Dengue might soon “take off” absent better mosquito eradication and screening prevention. U.S. Public Health experts say a Dengue foothold is nearly secured and the disease is fast on its way to becoming endemic in southern coastal states.
As for Yellow Fever, there is an effective vaccine, but it is also associated with rare but serious side effects. Antivaccine activism post-Covid would be a significant barrier now say experts. Adding to the challenge, no Yellow Fever vaccine is currently available from the U.S. Strategic National Stockpile. Mosquito surveillance programs are currently marginal, and response capabilities for mass vaccination in affected areas are severely limited.
The Anthropocene Workgroup is fully aware of these human instigated crises. In the prior Holocene Epoch of 11,700, we prided ourselves with being able to co-exist with other lifeforms and in equilibrium with a healthy planet. But beginning in 1950, the new Anthropocene Epoch has aggressively chipped away at planetary health, disrupting stabilizing cycles, and critically raising the temperature and acidity of oceans that cover and buffer 70% of the planet.
The return of Aedes aegypti, and the Yellow Fever virus it carries, is a dramatic harbinger of additional challenges to come if we are unable to limit “human perturbations” of our planetary cycles.
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Mike Magee MD is a Medical Historian and regular THCB contributor. He is the author of CODE BLUE: Inside America’s Medical Industrial Complex.
Jean-Claude Saghbini, Lumeris
Jean-Claude Saghbini is the CTO of Lumeris and also the President, Lumeris Value-Based Care Enablement. Lumeris has been in business quite a while now, providing the technology which (in general) hospitals and medical groups use to manage to their workflows predominantly for Medicare Advantage. It also owns a big medical group (Essence in St Louis) and has close connections with John Doerr of Kleiner Perkins fame, whose brother was involved in its formation. Kleiner also funded Healtheon (the precursor to WebMD) of which current Lumeris CEO Mike Long was the founding CEO. I interviewed Jean-Claude at HLTH to get the update on Lumeris. How are they helping those providers manage their patients at risk? How are those providers actually getting paid? And how that makes them behave. Plus his views on how CMS is adjusting the way Medicare scores and pays his clients! Matthew Holt
THCB Gang Episode 137, Thursday October 26
Joining Matthew Holt (@boltyboy) on #THCBGang on Thursday October 26 at 1pm PST 4pm EST were delivery & platform expert Vince Kuraitis (@VinceKuraitis); author & ponderer of odd juxtapositions Kim Bellard (@kimbbellard); futurist Ian Morrison (@seccurve); and our special guest was Kat McDavitt(@katmcdavitt) President of Innsena.
The video is below. If you’d rather listen to the episode, the audio is preserved from Friday as a weekly podcast available on our iTunes & Spotify channels
Y2Q and You
By KIM BELLARD
Chances are, you’ve at least somewhat concerned about your privacy, especially your digital privacy. Chances are, you’re right to be. Every day, it seems, there are more reports about data beeches, cyberattacks, and selling or other misuse of confidential/personal data. We talk about privacy, but we’re failing to adequately protect it. But chances are you’re not worried nearly enough.
Y2Q is coming.
That is, I must admit, a phrase I had not heard of until recently. If you are of a certain age, you’ll remember Y2K, the fear that the year 2000 would cause computers everywhere to crash. Business and governments spent countless hours and huge amounts of money to prepare for it. Y2Q is an event that is potentially just as catastrophic as we feared Y2K would be, or worse. It is when quantum computing reaches the point that will render our current encryption measures irrelevant.
The trouble is, unlike Y2K, we don’t know when Y2Q will be. Some experts fear it could be before the end of this decade; others think more the middle or latter part of the 2030’s. But it is coming, and when it comes, we better be ready.
Without getting deeply into the encryption weeds – which I’m not capable of doing anyway – most modern encryption relies on factoring unreasonably large numbers – so large that even today’s supercomputers would need to spend hundreds of years trying to factor. But quantum computers will take a quantum leap in speed, and make factoring such numbers trivial. In an instant, all of our personal data, corporations’ intellectual property, even national defense secrets, would be exposed.
“Quantum computing will break a foundational element of current information security architectures in a manner that is categorically different from present cybersecurity vulnerabilities,” warned a report by The RAND Corporation last year.
“This is potentially a completely different kind of problem than one we’ve ever faced,” Glenn S. Gerstell, a former general counsel of the National Security Agency, told The New York Times. “If that encryption is ever broken,” warned mathematician Michele Mosca in Science News, “it would be a systemic catastrophe. The stakes are just astronomically high.”
The World Economic Forum thinks we should be taking the threat very seriously. In addition to the uncertain deadline, it warns that the solutions are not quite clear, the threats are primarily external instead of internal, the damage might not be immediately visible, and dealing with it will need to be an ongoing efforts, not a one-time fix.
Even worse, cybersecurity experts fear that some bad actors – think nation-states or cybercriminals – are already scooping up troves of encrypted data, simply waiting until they possess the necessary quantum computing to decrypt it. The horse may be out of the barn before we re-enforce that barn.
Continue reading…Fay Rotenberg, CEO, Firefly Health
Fay Rotenberg is CEO of Firefly Health, which is an advanced virtual primary care group (a bastardized phrase she hates). That means they are both providing virtual care, with an integrated care and health plan coverage model, and are also a risk-bearing medical group working with other payers. They adjust the model using health guides, MDs, NPs, etc. and they help their patients manage their in person experience with specialists, labs, imaging, etc. — they have 1900+ partners nationwide who will actually know the patient is coming, and is integrated into Firefly’s model. Clinical outcomes are great, and costs are 12-15% lower, yet they have 5,000 members per MD. Maybe it really is the 21st century Kaiser?
“Doomscrolling” – Call the doctor!
by MIKE MAGEE
Exactly 1 year ago, mental health experts alerted the medical world to their version of an assessment scale for yet another new condition – “doomscrolling.”
As defined in the article, “Constant exposure to negative news on social media and news feeds could take the form of ‘doomscrolling’ which is commonly defined as a habit of scrolling through social media and news feeds where users obsessively seek for depressing and negative information.”
No one can deny a range of legitimate concerns. Faced with continued background noise from the pandemic, add global warming, renegade AI, and the Republican Congress. And now, the devastating attacks on Israel and growing instability in the Middle East. It is no wonder that we can’t turn off the Instagram feed.
With real challenges like these, our troubled world needs her doctors and nurses to stay focused more than ever on their primary professional missions – managing health and wellness, sickness and disease, fear and worry, and yes, now “doomscrolling.”
John J. Patrick PhD, in his book Understanding Democracy, lists the ideals of democracy to include “civility, honesty, charity, compassion, courage, loyalty, patriotism, and self restraint.” The 4.2 million registered nurses and 1 million doctors in America are agents of democracy.
Regrettably, they are already being drawn away from patients by three powerful forces.
- Corporate Dislocation – To assure maximum reimbursement, doctors and nurses are routinely asked to prioritize time and contact with data over time and access to patients.
- Health Technology and AI Substitution – Rather than engineering solutions to expand real-time patient contact, most innovations are further distancing patients from healthcare professionals.
- Legislative Intrusion – Complex medical decisions, long entrusted to the patient-health professional relationship to negotiate, are being transferred to ultra-conservative legislators.
We live under a constitutional and representative democracy, as do two-thirds of our fellow citizens in over 100 nations around the world. The health of these democracies varies widely. The case for democracy emphasizes its capacity to enhance dignity and self-worth, promote well-being, advance equal opportunity, protect equal rights, advance economic productivity, promote peace and order, resolve conflicts peacefully, hold rulers accountable, and achieve legitimacy through community-based action.
One of the challenges of democracy is to find the right balance in pursuing “the common good” which has dual (and often competing) arms. One arm is communitarian well-being and the other, individual well-being.
Continue reading…CMS’s Policy on Mental Health Therapists Will Work
By JON KOLE
Nearly 66 million Americans are currently enrolled in Medicare, a number that will likely swell towards 80 million Americans within the next seven years. These are our mothers, fathers, aunts, uncles, grandparents and friends – and, maybe, you.
A significant portion of these millions of people need mental health services – and, yet, many face long wait times or aren’t able to find a therapist at all. On average, Americans have a waiting period of 48 days before receiving mental health care. At present, two notable provider groups – Marriage and Family Therapists (MFTs) and Mental Health Counselors (MHCs), which summed to approximately 415,000 in 2021 – have not been eligible to provide psychotherapy for people with Medicare.
Currently, Medicare only approves psychologists and masters-level Licensed Clinical Social Workers (LCSWs) to provide therapy to Medicare recipients. In July, CMS proposed policies that would significantly increase access to mental health services by adding MFTs and MHCs into the ranks of Medicare-eligible providers. At a time where access to mental health services is acutely limited, it is startling that such a large pool of providers with advanced specialized degrees are not allowed to provide care.
There are many similarities between LCSWs and MFT/MHC training. In addition to an undergraduate degree, LCSWs, MFTs and MHCs have completed a two-year Master’s program, which is then followed by two years of supervised clinical practice prior to taking a licensure exam in their relevant discipline. Once they pass that test, they are able to practice independently in a wide range of settings.
Adding these trained professionals to the roster of available providers is a meaningful step to improve access to mental health services for Medicare members.
Improving access is not just about getting to a provider, though, t’s also about getting connected to one that a patient can feel safe with, connected to, and build a strong working rapport with. According to AAMFT, the satisfaction rate among patients engaged in care with a MFT is exceptionally high, with nearly 90% reporting an improvement in their emotional health after receiving treatment.
One key element in patient-provider connection is allowing options for demographic matching. Studies have shown that when patients from ethnic/racial minority backgrounds are able to connect with providers who share similar demographics, they report better health outcomes and increased satisfaction with the care provided. In one analysis, data gathered from Black caregivers showed 83 percent felt that having a mental health provider of the same race and ethnicity was important, citing themes like relatability, diversity in cultural experiences and the overall patient experience.Adding MFTs and MHCs has the potential to improve demographic matching, given that these are more diverse groups than PhDs or LCSWs.
Given the overall supply-demand imbalance, which is only predicted to get worse, the time is now to ensure that the entire qualified mental health labor force is able to work with Medicare recipients. The CMS proposal would do that.
Continue reading…Alex Katz, CEO, Two Chairs
Two Chairs has an interesting model. Their concept is to find the right therapist for you, and they actually start a patient off with a therapist who diagnoses AND directs in a session, separate from the one who treats. Once the “right” match is made, the patient gets set up with a therapist and the results have been pretty good in terms of the patient coming back–one of a number of things Two Chairs measures rather intently! CEO Alex Katz explained the model and the business–Matthew Holt.
